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Definition/Description

Adhesive capsulitis (AC), often referred to as frozen shoulder is characterized by initially painful and later progressively restricted active and passive glenohumeral joint range of motion with spontaneous complete or near complete recovery over varied period of time. For research purposes the condition is frequently defined as loss of more than 25% of normal shoulder range of motion in at least two directions,[1][2][3][4][5][6] particularly abduction and external rotation.

AC is associated with synovitis and capsular contracture of the shoulder joint. [1][2][3][4][5][7] In clinical practice it can be very challenging to differentiate early stage of AC from other shoulder pathologies.[1] Nevertheless, it is important for clinicians to be able to develop an early suspicion of this condition to benefit their patients. Physiotherapy management of patients with AC may vary in important ways from management of patients with other shoulder conditions.

Adhesive capsulitis is often more prevalent in women, individuals 40-65 years old, and in the diabetic population, with an occurrence rate of approximately 2-5% in the general population, [5][2][8][9][4][10] and 10-20% of the diabetic population.[9][10] If an individual has adhesive capsulitis they have a 5-34% chance of having it in the contralateral shoulder at some point. Simultaneous bilateral involvement has been found to occur in approximately 14% of cases.[2] Other associated risk factors include: trauma, prolonged immobilisation, thyroid disease, stroke, myocardial infarcts, and presence of autoimmune disease.[5][11]

The disease process affects the anteriosuperior joint capsule, axillary recess, and the coracohumeral ligament. It has been shown through arthroscopy that patients tend to have a small joint with loss of the axillary fold, tight anterior capsule and mild or moderate synovitis but no actual adhesions.[1][10] Contracture of the rotator cuff interval has also been seen in adhesive capsulitis patients, and greatly contributes to the decreased range of motion seen in this population.[2]

There is continued disagreement about whether the underlying pathology is an inflammatory condition, fibrosing condition, or an algoneurodystrophic process. Evidence suggests there is synovial inflammation followed by capsular fibrosis, in which type I and III collagen is laid down with subsequent tissue contraction.[1] Elevated levels of serum cytokines have been noted and facilitate tissue repair and remodeling during inflammatory processes. In primary and some secondary cases of adhesive capsulitis cytokines have shown to be involved in the cellular mechanism that leads to sustained inflammation and fibrosis. It is proposed that there is an imbalance between aggressive fibrosis and a loss of normal collagenous remodeling, which can lead to stiffening of the capsule and ligamentous structures.[2]

Characteristics/Clinical Presentation

Patients presenting with adhesive capsulitis will often report an insidious onset with a progressive increase in pain, and gradual decrease in active and passive range of motion.[2][8] Patients frequently have difficulty with grooming, performing overhead activities, dressing, and particularly fastening items behind the back.[11][4] Adhesive capsulitis is considered to be a self-limiting disease with sources stating symptom resolution as early as 6 months up to 11 years. Unfortunately symptoms may never fully subside in many patients.[11][2][12][13][5][8][14][3][4]

The literature reports that adhesive capsulitis progresses through three overlapping clinical phases:[1][4][13][11][7]

Acute/freezing/painful phase: gradual onset of shoulder pain at rest with sharp pain at extremes of motion, and pain at night with sleep interruption which may last anywhere from 3-9 months.

Adhesive/frozen/stiffening phase: Pain starts to subside, progressive loss of glenohumeral motion in capsular pattern. Pain is apparent only at extremes of movement. This phase may occur at around 4 months and last til about 12 months.

Resolution/thawing phase: Spontaneous, progressive improvement in functional range of motion which can last anywhere from 1 to 3.5 years.

Differential Diagnosis

Some conditions can present with similar impairments and should be included in the differential diagnosis. These include, but are not limited to, osteoarthritis, acute calcific bursitis/tendinitis, rotator cuff pathologies, parsonage-Turner syndrome, a locked posterior dislocation, or a proximal humeral fracture. [13][2]

Osteoarthritis (OA). Both may have limited abduction and external rotation AROM but with OA, PROM will not be limited. OA will also present with the most limitations with flexion whereas this is the least affected motion with adhesive capsulitis. Radiography can be used to rule out pathology of osseous structures.

Bursitis. Bursitis presents very similarly to adhesive capsulitis, especially compared to the early phases. Patients with bursitis will present with a non-traumatic onset of severe pain with most motions being painful. A main difference will be the amount of PROM achieved. Adhesive capsulitis will be extremely limited and painful whilst patients with bursitis, although painful, will have a larger PROM.

Parsonage-Turner Syndrome (PTS). PTS occurs due to inflammation of the brachial plexus. Patients will present without a history of trauma and with painful restrictions of all motions. The pain with PTS usually subsides much quicker than with adhesive capsulitis and patients eventually display neurological problems (atrophy of muscles or weakness) that are seen several weeks after the initial onset of pain.

Rotator Cuff (RC) Pathologies. The primary way to distinguish RC pathologies from adhesive capsulitis is to examine the specific ROM restrictions. Adhesive capsulitis presents with restrictions in the capsular pattern while RC involvement typically does not. RC tendinopathy may present similarly to the first stage of adhesive capsulitis because there is limited loss of external rotation and strength tests may be normal. MRI and ultrasonography can be used to identify soft tissue abnormalities of the soft tissue and labrum.

Posterior Dislocation. A posteriorly dislocated shoulder can present with shoulder pain and limited ROM, but, unlike adhesive capsulitis, it is related to a specific traumatic event. If the patient is unable to fully supinate the arm while flexing the shoulder, the clinician should suspect a posterior dislocation.

"Active Muscle Guarding" Hollmann et al. (2015) reported in their study that all of the patients suspected to have Frozen Shoulder showed a significant increase in range of motion under anesthesia, which confirms that some cases might have been falsely diagnosed with Frozen Shoulder and that the loss of range of motion cannot only explained by capsular contractions.[15]

Roy et al examined the psychometric properties of the SPADI, DASH, ASES and SST were examined.[17]Reliability, construct validity and responsiveness were all found to be favourable for various shoulder pathologies, but the review did not address their strength relative to adhesive capsulitis specifically.

Observation of posture and positioning

Scapular winging of the involved shoulder may be observed from the posterior and/or lateral views.[12]

Foraml ROM: Active/passive/overpressure

Shoulder Flex/ABd/ER/IR

The method of measuring ER and IR ROM in patients with suspected adhesive capsulitis varies in the literature.[10][21][22][23]

Patients with adhesive capsulitis commonly present with ROM restrictions in a capsular pattern. A capsular pattern is a proportional motion restriction unique to every joint that indicates irritation of the entire joint.[21] The shoulder joint has a capsular pattern where external rotation is more limited than abduction which is more limited than internal rotation (ER limitations > ABD limitations > IR limitations).[21][23] In the case of adhesive capsulitis, ER is significantly limited when compared to IR and ABD, while ABD and IR were not seen to be different.

Joint accessory mobility

Glenohumeral joint:

Anterior

Inferior

Posterior

Posterior capsule stretch

In patients with adhesive capsulitis, the anterior and inferior capsule will be the most limited but joint mobility will be restricted in all directions.[21]

Similar to ADLs such fitting a bra, putting on a jacket, getting into back pocket

Hand to opposite scapula (Figure 1C)

Shoulder flexion + horizontal adduction

These tests require appropriate elbow, scapulothoracic, and thoracic mobility and these areas should be cleared of pathology first. If a patient is unable to complete the motion, other structures outside of the shoulder joint may be the limiting factor.

Reliability of the three tests was excellent and correlation between them was moderate. [25]

These functional measures appear to be helpful for their objectivity in measuring shoulder dysfunction. However, even though the tests mimic fundamental ADL movements, the direct relationship between these tests and activities of daily living cannot be assumed.

Other

No specific clinical test for adhesive capsulitis has been reported in the literature and there remains no gold standard to diagnose adhesive capsulitis.[7] While there are no confirmed diagnostic criteria, a recent study determined a set of clinical identifiers that achieved a general consensus amongst experts for the early stages of primary (idiopathic) adhesive capsulitis.[7] The following tools can be used to help determine the stage of adhesive capsulitis and/or its irritability status.

Consensus was achieved on eight clinical identifiers collated into two discrete domains (pain and movement) as well as an age component.[7]

Pain

Strong component of night pain

Pain with rapid or unguarded movement

Discomfort lying on the affected shoulder

Pain easily aggravated by movement

Movement

Global loss of active and passive ROM

Pain at end-range in all directions

Onset

> 35 years of age

Medical Management

Although Adhesive Capsulitis is a self-limiting condition, it can take up to two to three years for symptoms to resolve and some patients may never fully regain full motion.[14] Treatment for pain, loss of motion, and limited function rather than take the wait-and-see approach is therefore important. Various interventions have been researched that address the treatment of the synovitis and inflammation and modify the capsular contractions such as oral medications, corticosteroid injections, distension, manipulation, and surgery. Even though many of these treatments have shown significant benefits over no intervention at all, definitive management regimens remain unclear. It is suggested that the primary treatment for adhesive capsulitis should be based around physical therapy and anti-inflammatory measures,[3] these outcomes, however, are not always superior to other interventions.[2]

Corticosteroid Injections

Corticosteroid injections are often used to manage inflammation as it is understood that inflammation is a key factor in the early stages of the condition. [27]The injections aim to reduce the painful synovitis occurring within the shoulder.[2][5] This can limit the development of fibrosis and adhesions within the capsule, potentially shortening the natural history of the disease.[5][1] Hence they are thought to be more useful in the early, painful and freezing stage of the condition due to the involvement of inflammation, rather than in the latter stages when fibrous contractures are more apparent.[3][14][1][28]

Methyl-prednisolone and Triamicinolone have both been found to be effective for injection use. There is no evidence suggesting the most effective treatment dose or administration site. The majority of the studies, however, used 20-40 mg injected via an anterior or posterior approach.[14]

Many studies have been performed and reviewed comparing corticosteroid injections to physical therapy, but results have been contradictory. It has been concluded that corticosteroid injections provide significantly greater short term benefits (4-6 weeks), especially in pain relief, but there is little to no difference in outcomes by 12 weeks compared to physical therapy.[3][5][2][14][28][29] The majority of studies, however, investigating corticosteroid injection as a treatment option do not define what stage the patients are in and had variations in the volumes of corticosteroid used. It has been shown that the benefits may not only be dose dependent, but also dependent on the duration of symptoms as well. [14][1] Therefore, the earlier the injection is received, the quicker the individual will recover. Contraindications to corticosteroids use include a history of infection, coagulopathy, or uncontrolled diabetes.[14]

Ultimately, corticosteroid injections have been shown to have success rates ranging from 44-80%[3] with rapid pain relief and improved function occurring mainly in the first weeks of treatment. It is a first line treatment for patients with pain as their predominant complaint in the early stages of adhesive capsulitis.[5][2] Though intra-articular steroid injection may be beneficial early on, its effect may be small and not well maintained[29] and should be offered in conjunction with physical therapy.[5][14]

Recommendations:

Injection for relieving shoulder disability and pain and physical therapy for improving motion in the painful freezing stage.[2][1]

If patients fail to progress within 3-6 weeks with physical therapy alone or patient's symptoms worsen, they should be offered the option of a corticosteroid injection.[2]

Manipulation under anesthesia (MUA)

Manipulation under anesthesia involves a controlled and forced, end range positioning of the humerus relative to the glenoid in physiologic planes of motion (flexion, abduction, rotation) in patients with an anesthetic block to the brachial plexus. The block allows the shoulder muscles to completely relax so that the force may actually reach the capsuloligamentous structures.[2]Traditionally, long lever arms were used, but now short lever arm techniques are utilised to minimise potential risks.[2][9] Although success rates are high, ranging from 75-100%,[2] manipulations are considered a last resort and are not indicated unless symptoms persist in spite of adequate conservative treatment for six months.[1][2][3][28] This is due to the numerous risks and complications such as: dislocation, glenoid, scapular, or humeral fracture, nerve palsy, rotator cuff tear, hemarthrosis, labral tears, and traction injuries of the brachial plexus or a peripheral nerve.[1][2][3][28] However, it has been shown that manipulations are the most reliable way to improve range of motion and reduce pain and disability in patients resistant to physical therapy[1][3] and these complications can be minimised with proper techniques and precautions. A good prognosis is often indicated if an audible and palpable release of the tissue occurs during the manipulation.[2]

An extensive post-manipulation programme begins immediately after release of the capsule.[2][9] They are often prescribed active assisted range of motion exercises that should be performed every two hours during waking hours, for the next 24 hours. Patients are also instructed to ice their shoulder for 20 minutes every two hours with their hand resting behind their head. Post manipulation programs are designed to maintain gains in shoulder mobility and should specifically address each individual's impairments.[2][9]

Contraindications to manipulation under anesthesia include: history of fracture or dislocations, moderate bone loss, or an inability to follow through with post procedure care.[2] Although manipulation under anesthesia has been shown to be effective in improving function and motion in patients with adhesive capsulitis, more randomised controlled trials comparing this treatment to competing treatments before widespread use are needed.[9]

Translation mobilisation under anesthesia

An alternative to traditional MUA is translation mobilisation under anesthesia, which has been identified in an attempt to avoid the complications associated with the traditional approach. This procedure involves the use of gliding techniques with static end range capsular stress with a short amplitude high velocity thrust, if needed, as opposed to the angular stretching forces in manipulation under anesthesia.[2][9]2 to 3 30 second sets of low velocity, oscillatory mobilisations (Maitland Grade IV-IV+) are performed initially in the same directions as traditional manipulation under anesthesia (anteriorly, posteriorly, and inferiorly). If an immediate increase in passive range of motion is not seen, a high velocity, low amplitude manipulation may be performed. This technique appears to be a safe and efficacious alternative for treatment of patients resistant to conservative treatment, however, higher level studies are needed for verification.[2]

If a patient has persistent symptoms, particularly in decreased shoulder motion, after at least 6 months of conservative treatment, manipulation under anesthesia is an effective technique to improve mobility, pain and disability.

Contraindications and complications do exist and should be relayed to the patient.

Arthroscopic capsular release

Arthroscopic capsular release is the preferred method over open release in patients with painful, disabling adhesive capsulitis that is unresponsive to at least 6 months of non-operative treatment. It has been found to be a reliable and effective method for restoring range of motion and is especially recommended for diabetics and in post-operative or post-fracture adhesive capsulitis patients.[3][1] It has become the most popular method of treating non-responsive adhesive capsulitis despite the lack of higher level trials comparing it to MUA.[28] This is because it allows a more controlled and selective release of the contracted capsule compared to manipulation which ruptures the capsuloligamentous structures and avoids the complications associated with MUA.[2][1] Debate exists over which structures should be arthroscopically released with the rotator cuff and coracohumeral ligament being the most common structures released.[2]

Recommendations:

If patient is unresponsive to at least 6 months of conservative treatment, arthroscopic capsular release alone or in conjunction with manipulation has been shown to be effective in restoring range of motion.

Avoids complications associated with manipulation under anesthesia and is recommended in diabetics and post-operative or post-fracture adhesive capsulitis patients.

Other

Non-steroidal anti-inflammatory drugs (NSAIDs) have traditionally been given to patients with adhesive capsulitis, but there is no high level evidence that confirms their effectiveness.[1][28]

Oral steroids have also been utilised in these patients and result in some improvement in function, but their effects have not shown long term benefits and combined with their known adverse side effects, should not be regarded as a routine treatment.[1][28][31]

Another technique that shows some short term benefit with rapid relief of symptoms is distension arthrography. This technique involves the injection of a solution (saline alone or combined with corticosteroids) causing rupture of the capsule by hydrostatic pressure.[3] It is still undetermined whether joint distension with saline solution combined with corticosteroids provides more benefit than distension with saline alone or corticosteroid injection alone.[3] There is a lack of reliable evidence when determining the effectiveness of this technique and further research needs to be performed to verify any clinical benefit.[3][28][33]

Suprascapular nerve blocks are thought to temporarily disrupt pain signals to allow normalisation of the pathological, neurological processes perpetuating pain and disability.[28] There is some evidence of benefit with suprascapular nerve blocks, though the exact mechanism behind this benefit remains unclear and higher level evidence is needed to establish this as a treatment for adhesive capsulitis.

According to a Cochrane review by Green et al,[34] there is little evidence to support or refute the use of any of the common interventions listed for adhesive capsulitis. There are also no studies with objective data supporting the timing of when to switch to invasive treatments such as manipulation under anesthesia or arthroscopic release which are not usually performed until 6 months of conservative treatment have been unsuccessful. Unfortunately this exposes more than 40% of patients with adhesive capsulitis to a long period of disability.[3]

Treatment should be tailored to the stage of the disease because the condition has a predictable progression.[1][28] During the painful freezing stage, treatment should be directed at pain relief with pain guiding activity. NSAIDs, physical therapy and steroid injection are all suggested interventions during this stage of adhesive capsulitis.[14][1] Once the patient is in the adhesive stage, injections are no longer indicated because the inflammatory stage of the disease has passed. The focus should instead switch to more aggressive stretching and MUA or surgical release if symptoms are unresponsive to conservative treatment and quality of life is compromised.[1][2][3][28]

Physical Therapy Management

The definitive treatment for adhesive capsulitis remains unclear even though multiple interventions have been studied. Previously published prospective studies of effective treatment have demonstrated conflicting results for improving shoulder range of motion in patients with this condition.[35](LoE: 4) Non-operative interventions include patient education, modalities, stretching exercises, and joint mobilisations.[2](LoE: 5)[4](LoE: 1a) Levine et al. reported that 89.5% of ninety eight patients with frozen shoulder responded well to non-operative management.[2](LoE: 5) Reviewed studies suggest that many patients have benefited from physical therapy and showed reduced symptoms, increased mobility, and/or functional improvement.[4](LoE: 1a) A Cochrane Review by Green et al, however, states that there is no evidence that physiotherapy alone is of benefit for adhesive capsulitis.[34](LoE: 1a)

Importance of patient education

For the treatment of adhesive capsulitis, patient education is essential in helping to reduce frustration and encourage compliance. It is important to emphasise that although full range of motion may never be recovered, the condition will spontaneously resolve and stiffness will greatly reduce with time. It is also helpful to give quality instructions to the patient and create an appropriate home exercise program that is easy to comply with as daily exercise is critical in relieving symptoms.[2](LoE: 5)

Modalities

Modalities, such as hot packs, can be applied before or during treatment. Moist heat used in conjunction with stretching can help to improve muscle extensibility and range of motion by reducing muscle viscosity and neuromuscular mediated relaxation.[2](LoE: 5) In a randomised study by Bal et al., patients improved with combined therapy which involved hot and cold packs applied before and after shoulder exercises were performed.[5](LoE: 1b) However, Jewell et al, claimed that ultrasound, massage, iontophoresis and phonophoresis reduced the chances of positive outcomes.[11](LoE: 2b)Green et al. suggested that there is no evidence of the effect of ultrasound in shoulder pain (mixed diagnosis), adhesive capsulitis or rotator cuff tendinitis.[34](LoE: 1a)

Initial Phase: painful, freezing

As alluded to, treatment should be customised to each individual based on the stage of the condition.

Pain relief should be the focus of the initial phase, also known as the painful, freezing Phase. During this time, any activities that cause pain should be avoided. Better results have been found in patients who performed simple pain free exercise, rather than intensive physical therapy [1](LoE: 3a) In patients with high irritability, range of motion exercises of low intensity and short duration can alter joint receptor input, reduce pain, and decrease muscle guarding. Stretches may be held from one to five seconds in a pain free range, 2 to 3 times a day.[2](LoE: 5) A pulley may be used to assist range of motion and stretch, depending on the patient’s ability to tolerate the exercise. Core exercises include pendulum exercise, passive supine forward elevation, passive external rotation with the arm in approximately 40 degrees of abduction in the plane of the scapula, and active assisted range of motion in extension, horizontal adduction, and internal rotation.[2](LoE: 5)

Although performed on a single patient only, Ruiz et al performed positional stretching of the coracohumeral ligament in the initial phase of adhesive capsulitis.[35](LoE: 4) The patient's Disabilities of Arm Shoulder and Hand (DASH) scores improved from 65 to 36 and Shoulder Pain and Disability Index (SPADI) scores improved from 72 to 8 and passive external rotation increased from 20 to 71 degrees. The stretches performed focused on providing positional low load and prolonged stretch to the CHL and the area of the rotator interval capsule following anatomical fibre orientation. The rationale behind this was to produce tissue remodelling through gentle and prolonged tensile stress on the restricting tissues. While a cause and effect relationship cannot be inferred from a single case, this report may help with further investigation regarding therapeutic strategies to improve function and reduce loss of range of motion in the shoulder and the role that the CHL plays in this.[35](LoE: 4)

In the case of adhesive capsulitis, physical therapy can also be a complement to other therapies (such as steroid injections as discussed previously), especially to improve the range of motion of the shoulder.[3](LoE: 3a)Bal et al suggested that concomitant exercises to steroid injections should include isometric strengthening in all ranges once motion returned to 90% of normal ranges, theraband exercises in all planes, scapular stabilisation exercises, and later, advanced muscular strengthening with dumbbells.[5](LoE: 1b)

Second Phase: adhesive

During the adhesive phase, the focus of treatment should be shifted towards more aggressive stretching exercises in order to improve range of motion. The patient should perform low load, prolonged stretches in order to produce plastic elongation of tissues and avoid high load, brief stretches, which would produce high tensile resistance.[1](LoE: 3a)

A prospective study by Griggs et al, demonstrated success of a non-operative treatment through a four-direction shoulder stretching exercise programme in which 90% of the patients reported a satisfactory outcome.[3](LoE: 3a) During the second phase of treatment, movement with mobilisation and end range mobilisations are recommended.[12](LoE: 1b) Mobilisation with movement can also correct scapulohumeral rhythm significantly better than end range mobilisation. The goal for end range mobilisation is not only to restore joint range, but also to stretch contracted peri-articular structures, whereas mobilisation with movement aims to restore pain free motion to the joints that had antalgic limitation of range of motion.[12](LoE: 1b)

Gaspar and Willis.[8](LoE: 2b) demonstrated that physical therapy paired with dynamic splinting had better outcomes compared to physical therapy alone or dynamic splinting alone. The patients in this group of combined treatments received physical therapy twice a week and a Shoulder Dynasplint System (SDS) for daily end range stretching. The combination of physical therapy with dynamic splinting had significant improvements in active, external rotation in patients with adhesive capsulitis.[8](LoE: 2b)

Third Phase: resolution

During stage three, treatment is progressed primarily by increasing stretch frequency and duration, whilst maintaining the same intensity, as tolerated by the patient. The stretch can be held for longer periods and the sessions per day can be increased. As the patient’s irritability level reduces, more intense stretching and exercises using a device, such as a pulley, can be performed to influence tissue remodelling. [2](LoE: 5)

Manual Techniques

Mechanical changes that occur as a result of mobilisations may include the break- up of adhesions, realignment of collagen, or increased fibre glide when specific movements stress certain parts of the capsular tissue. These techniques are intended to increase joint mobility by inducing changes in synovial fluid formation. High grade mobilisation techniques (HGMT) have been shown to be helpful for improving range of motion in patients with adhesive capsulitis for at least three months.[10](LoE: 1b) In a study by Vermeulen et al., patients were given inferior, posterior, and anterior glides as well as a distraction to the humeral head. These techniques were performed at greater elevation and abduction angles if glenohumeral joint range of motion increased during treatment. Patients who received HGMT received these mobilisations at Maitland Grades III and IV according to the subjects' tolerance with the intention of treating the stiffness. Patients were allowed to report a dull ache as long as it did not alter the execution of the mobilisations or persist for more than four hours after treatment. However, patients who received low-grade mobilisation techniques (LGMT) at Mailtand Grades I or II reported no pain. Statistically significant greater change scores were found in the HGMT group for passive abduction (at 3 and 12 months) and for active and passive external rotation (at 12 months) when compared with the low-grade mobilisation techniques. High grade mobilisation techniques appear to be more effective for increasing joint mobility and reducing disability.[10](LoE: 1b) Further studies are needed, however, to investigate whether HGMTs applied during earlier stages of adhesive capsulitis are as effective.[10](LoE: 1b)

Johnson et al. reported that joint mobilisations, in particular posterior glenohumeral glides, can help decrease deficits in external rotation, more so than anterior glenohumeral glides.[22](LoE: 1b) Both techniques had a significant decrease in pain, but there was greater improvement in external rotation range of motion with the posterior mobilisation treatment.[22](LoE: 1b) End range mobilisation is also more effective than mid-range mobilisation in increasing motion and functional mobility.[12](LoE: 1b) Overall, there are significant beneficial effects of joint mobilisation and exercise for patients with adhesive capsulitis.[11](LoE: 2b)

Rationale for stretching

Research regarding connective tissue stretch duration and intensity has produced 3 findings. Firstly, that high intensity, short duration stretching aids the elastic response, whilst low intensity, prolonged duration stretching aids the plastic response. Secondly, a direct correlation exists between the resulting proportion of plastic, permanent elongation and the duration of a stretch. Lastly, a direct correlation exists between the degree of either trauma or weakening of the stretched tissues and the intensity of a stretch. McClure et al, stated that the maximum TERT (Total End Range Time) or the total amount of time the joint is held at near end range position, will be different for each person and is often affected by personal circumstances such as their job or other responsibilities that may prevent a patient from increasing TERT.[35](LoE: 4)

Progression

Manual techniques and exercise should only be progressed as the patient’s irritability reduces. Patient response to treatment should be based on their pain relief, improved satisfaction, and functional gains, rather than restoration of range of motion. Usually, patients are discharged when significant pain reduction is reached, a plateau of motion gains are noticed for a period of time, and after improved functional motion and satisfaction have reached their peak.[2](LoE: 5) Progression for stretching via dynamic splinting is based on patient tolerance, as well. Gaspar and Willis, suggested that if patients experience discomfort or stiffness lasting more than an hour after the splint is removed, the duration of treatment is reduced for the next two stretching sessions. Only after stretching for a total of 60 minutes (30 minutes twice a day) is tolerated, is it suggested that the tension is then increased, every two weeks based on tolerance, without discomfort lasting more than one hour following every stretching session.[8](LoE: 2b)

Despite extensive research, further prospective randomised studies comparing different treatments are needed to formulate precise guidelines about diagnosis and treatment of idiopathic adhesive capsulitis.[3](LoE: 3a) The lack of validity, poor standardisation of terminology, methodology, and outcome measures in the investigations undermines clinical application. Therefore, more rigorous investigations are needed to compare the cost and effectiveness of physical therapy interventions.[4](LoE: 1a)

Description and scoring of the 3 function-related tests for the first stage of primary adhesive capsulitis. (Adapted from Yang et al, 2002, Reliability of function-related tests in patients with adhesive capsulitis, JOSPT, 36, p.573)

Hand-to-neck (shoulder flexion + external rotation)*

0 The fingers reach the posterior median line of the neck with the shoulder in full abduction and external rotation without wrist extension.

1 The fingers reach the median line of the neck but do not have full abduction and/or external rotation.

2 The fingers reach the median line of the neck but with compensation by adduction in the horizontal plane or by shoulder elevation

3 The fingers touch the neck

4 The fingers do not reach the neck

Hand-to-scapula (shoulder extension + internal rotation)¤

0 The hand reaches behind the trunk to the opposite scapula or 5cm beneath it in full internal rotation

1 The hand almost reaches the opposite scapula, 6-15 cm beneath it

2 The hand reaches the opposite illiac crest

3 The hand reaches the buttock

4 Subject cannot move the hand behind the trunk

Hand-to-opposite scapula (shoulder horizontal adduction)§

0 The hand reaches to the spine of the opposite scapula in full adduction without wrist flexion

1 The hand reaches to the spine of the opposite scapula in full adduction

2 The hand passes the midline of the trunk

3 The hand cannot pass the midline of the trunk

* This test measures an action essential for daily activities, such as using the arm to reach, pull, or hang an object overhead or using the arm to pick up and drink a cup of water.

¤ This test measures an action essential for daily activities, such as using the arm to pull an object out of a back pocket or tasks related to personal care.

§ This test measures an action important for daily activities, such as using the arm to reach across the body to get a car's seat belt or using the arm to turn a steering wheel.

Clinical Bottom Line

There is no definitive treatment for adhesive capsulitis. However, the literature suggests interventions should be tailored to the stage of the disease based on its progressive nature. During the initial/painful freezing stage, treatment should be directed at pain relief with pain guiding activity. NSAIDs and steroid injection, stretching, strengthening and range of motion exercises, as well as Maitland Grade I-II mobilisations have been shown to improve function and reduce pain and disability. As the patient progresses to the adhesive stage, intervention should focus on aggressive, end-range stretches combined with Maitland Grade III-IV mobilisations. At six months, if functional disability persists despite conservative treatment, mobilisations under anaesthesia (MUA) or arthroscopic capsular release may be indicated.

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